Making the Successful Transition from Physician to Medical Director

What brings physicians to choose to accept a position as a medical director in long-term care? It is less likely a lifelong passion specifically trained for, and more likely a position of circumstance—perhaps a plea from a desperate administrator, an opportunity to make a little more money, a passion for caring for the frail, or natural inclinations toward leadership and management. I most certainly never imagined myself in long-term care when I took a job at a county-run nursing home in 2000. It looked interesting, I needed work, I itched to lead, and they needed me.

When I joined what is now Edgemoor Distinct Part Skilled Nursing Facility, the county of San Diego was at a crossroads. Our facility was ancient, morale was skidding, there were concerns about the care and management, and our quality indicators were less than stellar. The question at that time was: Should Edgemoor rebuild (both literally and figuratively) or close? Fast-forward to 2009, and enter a beautiful, newly-built facility with a strong referral base, quality indicator scores to be proud of, and a cultural transformation that has given me an opportunity to reflect on how we have changed and what factors were instrumental in our success.

Being an excellent physician and being an excellent medical director require different skill sets and approaches. A physician often works alone and independently in a series of one-on-one brief interactions that involve a few minutes of listening and examining, cognitive skills to make a diagnosis and assessment, followed by the development of a plan (orders), which the physician expects to be implemented/followed. In contrast, medical directors work as a somewhat peripheral, mostly absent part of a team that is dominated by nursing culture, nursing perspective, and numerous regulations. The problems presented to medical directors are often too complex for short pronouncements. One thing that is common for both is that the physician may be treated deferentially face-to-face, but compliance with their excellent recommendations is often low. Physicians are often hurried and impatient; medical directors have to be extremely patient because things move slowly.

Through my experience, it appears that there are three components that are necessary in order to effect lasting change in an organization: leadership, partnership, and culture change. The medical director is one component of the leadership of the facility. Ideally, there is a triad of power with the director of nursing, the administrator, and the medical director. However, this triad can be complicated in systems with “corporate offices” or when there are other individuals who wield strong formal and informal power. In reality, the medical director may have little real power to implement an agenda. Much more power lies with nursing (it is a nursing home, after all) or administration. Medical directors are sort of like the Judicial branch of the U.S. government: They issue decisions but have no actual power to implement them (the role of the Executive branch) or to fund them (the power held by the Legislative branch). The Judicial branch can put a halt to things that are terrible or occasionally surprise everyone with a new perspective.

Medical directors cannot be effective without forging effective, mutually beneficial relationships with the other leaders and using their influence to get others’ buy-in for change and improvement. Buy-in is allocation of resources, which may be financial, time, or energy. And buy-in is responsiveness—attention and support to the change initiative. When a medical director is planning a new initiative (for example, our initiative to go “smoke-free” or “restraint-free” or to reduce in-house pressure ulcers), it is best to plant the seed of an idea early, well before one plans a change initiative. Speak off-handedly about the idea and back away: “Did you know some facilities use no restraints at all? How can that be?” Once an idea is planted, individuals will automatically become more attentive to the conversations, articles, and thinking about that idea. This has been termed the “sleeper effect” by psychologists.

A second key to organizational change is partnership. Effective partnerships align individual visions with organizational goals—this is how medical directors get buy-in from those implementing the change. The best partnerships are strength- and passion-based, identifying a champion to spearhead the initiative and assuring that the team has members with various strengths: detail-oriented people, optimists, finishers, and those who can sell ideas both up and down the chain. The medical director may be the champion—encouraging others, reviewing progress, helping negotiate relationships and roadblocks, and helping the organization to see and publicize the success.

The challenge of this approach is that instead of “overt” action on the medical director’s part, he/she may be performing more “covert operations.” Their ideas may be attributed to others, and they may spend more time getting others to buy in than actually working on solving the problem. The solutions that the group generates may not be as good as the medical director’s, or the medical director may not be in control of the outcome. Sometimes, one may even feel that he or she is not doing anything at all (I often just walk around talking to people about what’s going on instead of doing work!). The upside is that many people become invested in the projects, the ideas generated are more likely sustainable, and, in reality, one can do much more working through others than by oneself—and the changes made in this way are much more sustainable.

Perhaps the most critical aspect of sustainable organizational change is culture. Culture is based on training and experience, as well as differences in perspectives, ethnic differences, and differences in approaches to problems. Different disciplines have their cultures, organizations have their cultures, departments or work groups have their cultures. Without understanding the culture of an organization and aligning your initiative with the culture, or changing the culture, lasting change is not possible. As was stated so eloquently by Dr. Angelo Kinicki, “Culture eats strategy for breakfast.”¹

Dealing with nursing culture was one of the biggest challenges I faced in long-term care leadership. Until I invested the time to learn about nursing perspectives by reading care plans, the Minimum Data Set (MDS) and MDS manual, listening to nurses, reading the state and federal regulations, reading their procedures, and learning nursing diagnoses, I did not really understand nursing. I passed medications one day, and it was extremely eye-opening. I was very grateful to be a physician and not a nurse. I realized that nurses’ training, their approach, and their world view are completely different from mine. Nurses have a strong task orientation, while a doctor’s orientation is much more theoretical. However, when I learned to become “bicultural,” I had much more success in communicating with nurses and in making improvements in nursing practices at my facility.

As a leader, the medical director’s job is to make the pursuit of excellence and constant learning a habit and a part of the culture of the organization. There is a culture of respect for physicians, and nurses will agree with them, nod to their ideas, and tell them how helpful they have been. I challenge medical directors, however, to not be fooled. Often, the way things are “really” being done is very different from what medical directors are shown. Look deeper and listen harder. No matter how good one’s idea is, if it doesn’t meld with the organizational culture, it won’t succeed. Culture is the single strongest part of the organization.

Medical directors wear many hats. Sometimes they are the primary physicians for individual patients. Other times, they are a part of a quality improvement team and may be brainstorming or throwing out suggestions. They may be auditing the charts of other physicians and communicating about ways to improve practice. Medical directors may be issuing a directive that is not negotiable, while other times they are visionary leaders, inspiring others with innovative ideas for the future and its possibilities.

I have found that medical directors get into trouble when they do not make it clear what hat they are wearing—team member, primary physician, administrative representative, manager, etc. Medical directors must be clear with themselves and with others as to what hat they are wearing at the moment. They must remember that they are always being watched, so every action and every utterance must be furthering an agenda of the kind of organization they want to be working for.

Physicians are generally not formally trained in management and leadership. Being a medical director is like being in residency—one is learning on the job for the most part. So how do medical directors get good at it? How can they be masterful or be honored with Medical Director of the Year Award? Mastery is experience plus reflection—we try things, we reflect on them, we read about leadership, management, best practices, and clinical practice guidelines; we discuss with our colleagues, and we reflect on our situation, our patients, our organization. And we try more things. Understanding our strengths and emphasizing work in areas of our greatest passion is the best way to maximize our efficiency and most effectively influence others. Because there are so many problems to solve and so many ways to improve on ourselves and our organizations, medical directors have endless opportunities to strive for the elusive goal of mastery.

Dr. Ferrini is a full-time medical director at Edgemoor Distinct Part Skilled Nursing Facility in Santee, CA. She was honored in 2009 as the American Medical Director’s Association “Medical Director of the Year.”